AbstractBackground: Enhanced Recovery After Surgery (ERAS) programs are increasingly used in pediatric surgery, but high-quality randomized evidence specific to pediatric appendectomy is limited. We evaluated whether a standardized pediatric ERAS pathway improves recovery without compromising safety in children undergoing laparoscopic appendectomy.
Methods: In a multicenter, parallel-group randomized controlled trial, 200 children (5-17 years) with imaging-confirmed acute appendicitis scheduled for laparoscopic appendectomy were allocated 1: 1 to a pediatric ERAS bundle or usual perioperative care. The ERAS pathway comprised preoperative education and fasting optimization with carbohydrate loading; multimodal, opioid-sparing analgesia; antiemetic prophylaxis; normothermia; goal-directed fluids; de-implementation of routine drains/tubes; early oral intake and mobilization; and criteria-based discharge. The primary outcome was postoperative length of stay (LOS). Secondary outcomes included time to first oral intake and ambulation, inpatient opioid exposure (morphine milligram equivalents/kg), highest pain score at 24 h, postoperative nausea and vomiting (PONV), 30-day complications, emergency department revisits/readmissions, parent satisfaction, and in-hospital costs. Analyses were intention-to-treat with prespecified adjustments for site and appendicitis severity; fidelity and per-protocol sensitivity analyses were performed.
Results: ERAS reduced LOS (mean ± SD: 24 ± 16 h) versus usual care (36 ± 24 h), adjusted mean difference −10.8 h (95% CI −14.6 to −7.0; p < 0.001). Time to oral intake (4 ± 3 h vs. 12 ± 7 h) and ambulation (8 ± 6 h vs. 18 ± 11 h) were shorter with ERAS (both p < 0.001). Inpatient opioid exposure decreased from 0.35 ± 0.20 to 0.15 ± 0.10 MME/kg (p < 0.001), with fewer patients receiving any opioid (19% vs. 41%; p < 0.001); pain scores at 24 h were modestly lower. Thirty-day complications (6% vs. 8%), surgical-site infection (3% vs. 4%), emergency revisits (6% vs. 7%), and readmissions (3% vs. 4%) were similar between groups. Parent satisfaction was higher with ERAS. Element-level adherence averaged ~82%, and greater adherence correlated with shorter LOS.
Conclusion: A standardized pediatric ERAS pathway for laparoscopic appendectomy significantly accelerates recovery and reduces opioid exposure without increasing adverse events or unplanned utilization. These data support routine adoption with fidelity monitoring and audit-feedback to sustain benefits at scale.
